Bernthal Elizabeth M M, Russell R J, Draper H J A
Academic Department of Military Nursing, Royal Centre for Defence Medicine (Academia and Research) Medical Directorate, Birmingham, UK.
Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Academia and Research) Medical Directorate, Birmingham, UK.
J R Army Med Corps. 2014 Jun;160(2):196-202. doi: 10.1136/jramc-2013-000214. Epub 2014 Jan 16.
The aim of the study was to explore how useful clinicians deployed to the Field Hospital in Afghanistan found using the four quadrant approach (4QA) as a tool to aid ethical decision-making. In addition, the study aimed to determine whether the 4QA needed to be amended to make it more effective in assisting the ethical decision-making process for military health professionals on deployment.
A qualitative pilot study in two phases was undertaken between September 2012 and January 2013. In Phase I, senior deployed clinicians completed a pro forma of the 4QA on cases that potentially raised ethical issues. Thirteen pro formas were submitted on four cases; the Deployed Medical Director submitted a log of 14 cases that had involved using the 4QA. Phase II consisted of interviews with five senior clinicians who had recently returned from deployment in Afghanistan to discuss their experiences and perceptions of using the 4QA.
Phase I identified a variation in the level of detail recorded and where that information was placed on the quadrant. Four themes were generated from Phase II. These included the characteristics of ethical decisions; the processes used to make ethical decisions; use, usefulness and limitations of the 4QA; and views about training in ethics. The findings suggested that amendments to the pro forma may improve its utility.
The 4QA is a useful tool within an operational setting but amending its diagrammatic presentation could improve its effectiveness. Pre-deployment training should include practising using the quadrant as described in Clinical Guidelines for Operations. This is particularly important as the participants relied heavily on experience to help them make ethical decisions, and this experience may not be available in future operations outside Afghanistan.
本研究旨在探讨被部署到阿富汗野战医院的临床医生发现使用四象限方法（4QA）作为辅助伦理决策工具的有用程度。此外，该研究旨在确定4QA是否需要修订，以使其在协助部署中的军事卫生专业人员进行伦理决策过程中更有效。
在2012年9月至2013年1月期间进行了一项分两个阶段的定性试点研究。在第一阶段，资深的部署临床医生就可能引发伦理问题的病例填写了4QA的格式表。针对四个病例提交了13份格式表；部署的医疗主任提交了一份涉及使用4QA的14个病例的记录。第二阶段包括对五名最近从阿富汗部署归来的资深临床医生进行访谈，以讨论他们使用4QA的经验和看法。
第一阶段发现记录的详细程度以及该信息在象限中的位置存在差异。从第二阶段产生了四个主题。这些主题包括伦理决策的特征；做出伦理决策所使用的过程；4QA的使用、有用性和局限性；以及关于伦理培训的看法。研究结果表明，对格式表进行修订可能会提高其效用。
4QA在作战环境中是一个有用的工具，但修改其图表呈现方式可以提高其有效性。部署前培训应包括按照《作战临床指南》中所述练习使用象限。这一点尤为重要，因为参与者严重依赖经验来帮助他们做出伦理决策，而这种经验在未来阿富汗以外的行动中可能无法获得。
